190 Guideline
Learning, techniques, and complications of
endoscopic ultrasound (EUS)-guided sampling
in gastroenterology: European Society of Gastro-
intestinal Endoscopy (ESGE) Technical Guideline
Authors
Institutions
submitted 10. May 2011
accepted after revision
10. October 2011
Bibliography
DOI http://dx.doi.org/
10.1055/s-0031-1291543
Published online: 16.12.2011
Endoscopy 2012; 44: 190205
Georg Thieme Verlag KG
Stuttgart New York
ISSN 0013-726X
Corresponding author
M. Polkowski, MD
Department of
Gastroenterology,
The M. Sklodowska-Curie
Memorial Cancer Center and
Institute of Oncology,
Roentgena 5
02781 Warsaw
Poland
Fax: +48-22-5463035
mp.polkowski@gmail.com
Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
M. Polkowski1, A. Larghi2, B. Weynand3, C. Boustire4, M. Giovannini5, B. Pujol6, J.-M. Dumonceau7
Institutions are listed at the end of article.
This article is the second of a two-part publication
that expresses the current view of the European
Society of Gastrointestinal Endoscopy (ESGE)
about endoscopic ultrasound (EUS)-guided sam-
pling, including EUS-guided fine needle aspira-
tion (EUS-FNA) and EUS-guided Trucut biopsy.
The first part (the Clinical Guideline) focused on
the results obtained with EUS-guided sampling,
and the role of this technique in patient manage-
ment, and made recommendations on circum-
stances that warrant its use. The current Techni-
cal Guideline discusses issues related to learning,
techniques, and complications of EUS-guided
sampling, and to processing of specimens. Techni-
cal issues related to maximizing the diagnostic
1. Introduction
! phy and words pertinent to specific key ques-
The current Technical Guideline discusses issues
related to the learning, techniques, and complica-
tions of endoscopic ultrasound (EUS)-guided
sampling and to processing of specimens obtain-
ed with EUS-guided fine needle aspiration (EUS-
FNA) or EUS-guided Trucut biopsy (EUS-TCB).
The results of EUS-guided sampling in various
clinical indications, the role of this technique in
patient management, and recommendations on
its use are discussed in the associated Clinical
Guideline from the European Society of Gastroin-
testinal Endoscopy (ESGE) [1].
2. Methods
! subsequent Guideline version was discussed
The ESGE commissioned and funded this
Guideline. The method for guideline development
was similar to that used for other ESGE Guidelines
[2, 3]. Briefly, subgroups were formed, each
charged with a series of clearly defined key ques-
tions (see " Appendix e1, available online). The
committee chair worked with subgroup leaders
to identify pertinent search terms that always in-
yield (e. g., rapid on-site cytopathological evalua-
tion, needle diameter, microcore isolation for his-
topathological examination, and adequate num-
ber of needle passes) are discussed and recom-
mendations are made for various settings, includ-
ing solid and cystic pancreatic lesions, submuco-
sal tumors, and lymph nodes. The target reader-
ship for the Clinical Guideline mostly includes
gastroenterologists, oncologists, internists, and
surgeons while the Technical Guideline should
be most useful to endoscopists who perform
EUS-guided sampling. A two-page executive sum-
mary of evidence statements and recommenda-
tions is provided.
cluded, as a minimum, endoscopic ultrasonogra-
tions. Evidence tables were generated for each
key question based on meta-analyses or random-
ized controlled trials (RCTs) if these were avail-
able; otherwise, case control studies, retrospec-
tive analyses, and case series were included. The
number of articles retrieved and selected for
each task force is indicated in the Evidence table
(see " Appendix e2, available online). Evidence
levels and recommendation grades used in these
guidelines were those recommended by the
amended Scottish Intercollegiate Guidelines Net-
work (SIGN) ( " Table 1) [4]. Subgroups agreed
electronically on draft proposals that were pres-
ented to the entire group for general discussion
during two meetings held in 2010 and 2011. The
using electronic mail until unanimous agreement
was reached. Searches were re-run in February
2011 (this date should be taken into account for
future updates). The final draft was approved by
all members of the Guideline development group;
it was sent to all individual ESGE members in
April 2011 and, after incorporation of their com-
ments, it was endorsed by the ESGE Governing

Table 1 Definitions of categories for evidence levels and recommendation
grades used in this guideline [4].
Evidence level
1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs
with a very low risk of bias
1+ Well conducted meta-analyses, systematic reviews of RCTs, or
RCTs with a low risk of bias
1 Meta-analyses, systematic reviews, or RCTs with a high risk of
bias
2++ High quality systematic reviews of case control or cohort
studies; high quality case control studies
or cohort studies with a very low risk of confounding, bias, or
chance and a high probability that the relationship is causal
2+ Well conducted case control or cohort studies with a low risk
of confounding, bias, or chance and a moderate probability that
the relationship is causal
2 Case control or cohort studies with a high risk of confounding,
bias, or chance and a significant risk that the relationship is not
causal
3 Nonanalytic studies, e. g. case reports, case series
4 Expert opinion
Recommendation grades
A At least one meta-analysis, systematic review, or RCT rated as
1 + + and directly applicable to the target population
or a systematic review of RCTs
or a body of evidence consisting principally of studies rated
as 1 + directly applicable to the target population and demon-
strating overall consistency of results
B A body of evidence including studies rated as 2 + + directly
applicable to the target population and demonstrating overall
consistency of results
or extrapolated evidence from studies rated as 1 + + or 1 +
C A body of evidence including studies rated as 1 or 2 + directly
applicable to the target population and demonstrating overall
consistency of results
or extrapolated evidence from studies rated as 2 + +
D Evidence level 2 , 3 or 4
or extrapolated evidence from studies rated as 2 +
RCT, randomized controlled trial
Board prior to submission to Endoscopy for international peer re-
view. The final revised version was approved by all members of
the Guideline development group before publication.
Evidence statements and recommendations are stated in italics,
key evidence statements and recommendations are in bold. This
Guideline will be considered for review in 2014, or sooner if im-
portant new evidence becomes available. Any updates to the
Guideline in the interim period will be noted on the ESGE web-
site: http://www.esge.com/esge-guidelines.html.
3. Summary of statements and recommendations
! vides a highly reliable diagnosis with an excellent agreement with
Learning EUS-FNA
EUS-FNA is an extension of EUS; all endoscopists who reported their
learning curve for EUS-FNA had prior experience in EUS. Material
available for learning EUS-FNA includes common didactic material
(e. g., books, videos), various types of simulators, and live pigs.
Among models available for hands-on training, live pigs are the
most realistic and could allow the improvement of EUS-FNA skills
but are not widely available. The learning process of EUS-FNA has
been studied for solid pancreatic lesions only; it showed a learning
curve with increasing sensitivity for the cytopathological diagnosis
of cancer (reaching 80 % after 20 30 EUS-FNA), decreasing number
Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
Guideline 191
of passes needed to obtain adequate results (reaching a median of 3
after 150 EUS-FNA), but no variation in severe morbidity. In all re-
ported studies, rapid on-site cytopathological examination (ROSE)
was used to guide the number of FNA passes needed (Evidence level
2 +).
Trainees should demonstrate competence in linear EUS before
undertaking EUS-FNA. We discourage self-learning of EUS-FNA.
We recommend combination of the use of different simulators
and, if available, live pigs, during training in EUS-FNA. We recom-
mend that a minimum of 20 and 30 supervised EUS-FNAs of non-
pancreatic and pancreatic lesions, respectively, be performed
with ROSE before assessment of competency in these techniques
(Recommendation grade C). ROSE is preferable although direct
supervision by an endosonographer experienced in EUS-FNA
can be another option. Close collaboration with a cytopathologist
experienced in evaluation of EUS-FNA samples is recommended
(Recommendation grade D).
Techniques of EUS-FNA
For EUS-FNA of pancreatic lesions the 19G, 22G and 25G needles are
characterized by similar diagnostic yields (Evidence level 1 + ) and
safety profiles (Evidence level 1 ). Although 19G needles provide a
higher amount of cellular material than do thinner needles, and, if
technically successful, offer better diagnostic yield, these advanta-
ges are offset by a higher rate of technical failures in the case of le-
sions that need to be punctured from the duodenum (Evidence level
1 ). Studies comparing EUS-FNA needles of different sizes in indi-
cations other than pancreatic masses are lacking. We recommend
against using 19G needles for transduodenal biopsy (Recommenda-
tion grade C).
Applying continuous suction with a syringe during EUS-FNA improves
the sensitivity for the diagnosis of malignancy in patients with solid
masses but not in patients with lymphadenopathy (Evidence level
1 ). We recommend using suction for EUS-FNA of solid masses/cys-
tic lesions and not using suction for EUS-FNA of lymph nodes (Re-
commendation grade C).
Using the needle stylet does not seem to impact EUS-FNA sample
quality and results (Evidence level 1 ). There is insufficient evidence
to recommend for or against using the stylet and the decision in this
regard should be left to the discretion of the endosonographer per-
forming the procedure (Recommendation grade C).
Diagnostic accuracy of EUS-FNA does not differ depending on wheth-
er the sampling is performed from the edge of a lymph node or from
its center (Evidence level 1 ). No data on this topic are available for
lesions other than lymph nodes. We recommend sampling all parts
of solid lesions or lymph nodes (Recommendation grade C) and
sampling any solid component inside pancreatic cysts and the
wall of the cyst (Recommendation grade D).
Gross visual inspection is unreliable in assessing the adequacy of
EUS-FNA specimens for cytopathological examination. ROSE pro-
the final cytopathological diagnosis (Evidence level 2 + ). There is
limited evidence to suggest that ROSE increases the diagnostic yield
of EUS-FNA (Evidence level 2 ). The diagnostic yield of EUS-FNA
with ROSE in most studies exceeds 90 %; however, similarly good re-
sults have been reported from selected studies without ROSE. (Evi-
dence level 2 + ). Data on cost effectiveness of ROSE are very lim-
ited. In view of these data, it is felt that implementation of ROSE
should be considered especially during the learning phase of EUS-
FNA and at centers in which specimen adequacy rates are below
90 % (Recommendation grade D).
192 Guideline
Various studies have investigated the adequate number of needle
passes that should be performed if ROSE is not used. Discordant
conclusions have been reached for solid masses, while more concor-
dant results have been reported for lymph nodes, liver lesions, and
pancreatic cysts. We recommend performing 3 needle passes for
lymph nodes and liver lesions, at least 5 needle passes for solid pan-
creatic masses, and a single pass for pancreatic cysts (Recommen-
dation grade C).
Techniques to obtain tissue for histopathological
evaluation
EUS-FNA with standard needles can provide tissue adequate for histo-
pathological evaluation from most pancreatic tumors (Evidence level
2 + ). Combining EUS-FNA histology and EUS-FNA cytology seems to
increase EUS-FNA diagnostic yield (Evidence level 2 ) and sensitiv-
ity for pancreatic cancer detection (Evidence level 2 + ). Other po-
tential advantages of EUS-FNA histology consist of facilitated im-
munostaining and better capability to diagnose specific tumor
types (Evidence level 2 ). We suggest implementation of this tech-
nique into routine practice (Recommendation grade D).
Transduodenal EUS-TCB is characterized by a very high failure rate
(Evidence level 2 + ). For non-transduodenal routes, the failure rate is
low and the accuracy for the detection of malignancy is similar to
that of EUS-FNA (Evidence level 2 + ). The accuracy of dual sampling
(EUS-TCB + EUS-FNA) is superior to either technique alone (Evi-
dence level 2 + ). Sequential sampling (EUS-TCB with EUS-FNA res-
cue) has similar accuracy to that of dual sampling (Evidence level
2 ). EUS-TCB is superior to EUS-FNA in establishing some specific
diagnoses, especially of benign tumors or if immunostaining is re-
quired (Evidence level 2 ). In most instances EUS-TCB does not of-
fer advantages over EUS-FNA; however, EUS-TCB should be consid-
ered when tissue architectural details and immunostaining are re-
quired to establish a specific diagnosis (Recommendation grade C).
Specimen processing
No adequate study has compared direct smear cytology vs. liquid-
based cytology (LBC) for processing specimens collected with EUS-
FNA. Similarly, no study has evaluated which of the methods de-
scribed for collecting tissue fragments for histopathological exami-
nation is better. In the case of suspected tuberculosis or lymphoma,
polymerase chain reaction (suspected tuberculosis) on histopatholo-
gical specimens and flow cytometry (suspected lymphoma), after
placement of the collected specimen in an adequate transport medi-
um have, been shown to significantly increase the diagnostic yield
(Evidence level 2 + ). The specific method to be used for both cytopa-
thological processing and collection of histopathological specimens
should be left to the discretion of each center, depending on their
confidence with available methods (Recommendation grade D).
Cell blocks can be used as a complement to rather than a replace-
ment for smears or LBC (Recommendation grade D). If tuberculosis
is suspected, then polymerase chain reaction should be used; if
lymphoma is suspected then flow cytometry should be used (Re-
commendation grade C).
Complications of EUS-FNA and their prevention
EUS-FNA is a safe procedure with a complication rate of approxi-
mately 1 % (Evidence level 2 + + ). Complications include infection,
bleeding, and acute pancreatitis; they are more frequent for EUS-
FNA of cystic compared with solid lesions (Evidence level 2 ). Bac-
teremia is rare after EUS-FNA, including that of perirectal and rectal
lesions (Evidence level 2 + + ). The 19G, 22G, and 25G EUS-FNA needles
present similar complication rates. Transesophageal and transgas-
Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
tric EUS-TCB have similar safety profiles compared with EUS-FNA, at
least in experienced hands (Evidence level 1 ). Aspirin/nonsteroidal
anti-inflammatory drugs (NSAIDs) do not seem to increase the risk
of bleeding following EUS-FNA (Evidence level 2 ).
Antibiotic prophylaxis is recommended before EUS-guided sam-
pling of cystic lesions (Recommendation grade C) but not of solid
lesions (Recommendation grade B). Antibiotic prophylaxis of infec-
tive endocarditis is not recommended (Recommendation grade B).
Coagulation check-up is recommended before EUS-FNA only in pa-
tients with a personal or family history suggesting bleeding disor-
der or with a clear clinical indication (Recommendation grade C).
EUS-guided sampling should not be performed in patients treated
with oral anticoagulants (Recommendation grade C) or thienopyr-
idines (Recommendation grade D). In addition, treatment with as-
pirin or NSAIDs is a contraindication for EUS-guided sampling of
cystic lesions (Recommendation grade C).
EUS-TCB is contraindicated for lesions requiring a transduodenal
approach, lesions < 20 mm or of cystic appearance, and when the
operator has limited experience with standard EUS-FNA (Recom-
mendation grade D).
4. Learning EUS-FNA
!
EUS-FNA is an extension of EUS; all endoscopists who reported their
learning curve for EUS-FNA had prior experience in EUS. Material
available for learning EUS-FNA includes common didactic material
(e. g., books, videos), various types of simulators, and live pigs.
Among models available for hands-on training, live pigs are the
most realistic and could allow the improvement of EUS-FNA skills
but are not widely available. The learning process of EUS-FNA has
been studied for solid pancreatic lesions only; it showed a learning
curve with increasing sensitivity for the cytopathological diagnosis
of cancer (reaching 80 % after 20 30 EUS-FNA), decreasing number
of passes needed to obtain adequate results (reaching a median of 3
after 150 EUS-FNA), but no variation in severe morbidity. In all re-
ported studies ROSE was used to guide the number of FNA passes
needed (Evidence level 2 + ).
Trainees should demonstrate competence in linear EUS before un-
dertaking EUS-FNA. We discourage self-learning of EUS-FNA. We
recommend combination of the use of different simulators and, if
available, live pigs, during training in EUS-FNA. We recommend
that a minimum of 20 and 30 supervised EUS-FNA of non-pancre-
atic and pancreatic lesions, respectively, be performed with ROSE
before assessment of competency in these techniques (Recommen-
dation grade C). ROSE is preferable although direct supervision by
an endosonographer experienced in EUS-FNA can be another op-
tion. Close collaboration with a cytopathologist experienced in
evaluation of EUS-FNA samples is recommended (Recommendation
grade D).
4.1. Training in EUS-FNA
The results of two methods for learning EUS-FNA have been re-
ported, i. e. formal training, consisting of fellowship in a dedica-
ted training center for 6 24 months, and informal training, con-
sisting of short repeated exposures to various didactic situations
that usually included short hands-on experiences [5]. Formal
training programs are scarce in Europe and even in countries
where they are most developed (e. g., France), they allow training
of only a small number of endoscopists per year [6 8]. In addi-
tion, the long duration of formal training programs is impractical
for the practicing, experienced endoscopist. The proportion of

Table 2 Series reporting the learning curve for endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) of solid pancreatic lesions.
First author, Patients/ Operator
year operators, n/n experience prior
to study period
Harewood, 65 /3 > 300 EUS
2002 [15] < 10 EUS-FNA
Mertz, 2004 57 /1 132 EUS
[14] No EUS-FNA
Eloubeidi, 2005 300 /1 316 EUS
[13] 45 EUS-FNA
1
Mentoring during the performance of 2 to 10 pancreatic EUS-FNAs by an experienced endosonographer
2
Including major complications (oversedation that required the administration of a reversal agent or hospitalization or emergency department visit) in 2 % of patients
endosonographers who report that they are self-taught varies
between 8 % and 50 % [9 11]. Although unalloyed self-education
is feasible for simple endoscopic procedures while maintaining
high quality and safety standards [12], it has not been reported
for more complex procedures such as EUS-FNA [5].
It seems reasonable to assume that any training has to be foun-
ded on theoretical and clinical knowledge [7]. Furthermore, all
of the endoscopists who reported their learning curve for EUS-
FNA had performed diagnostic EUS before performing supervised
EUS-FNA [13 15]. Competence in percutaneous abdominal ul-
trasound is not a prerequisite for EUS or EUS-FNA because no evi-
dence was found in the literature that it improves competence in
EUS. Criteria useful for assessing whether competence in EUS has
been reached are available [16].
The use of textbooks and videos is recommended in most con-
sensus statements as a basis for EUS training. Hands-on training
in EUS-FNA has used: (i) phantoms devoid of animal material
(Olympus, Tokyo, Japan; self-made phantoms constructed with
commonly available materials); (ii) models using porcine organs
(upper and lower digestive EUS-FNA) [17 19]; and (iii) live pigs
[20]. Simulators (www.simbionix.com) do not currently offer
training in FNA. All of these models have been subjected to feasi-
bility studies only, except for the live pig model. The latter was
evaluated during a 4-week EUS course: a significant improve-
ment was noted in terms of duration and precision of the proce-
dure between the first and second attempt at FNA of lymph
nodes at the liver hilum [6]. This model was judged by eight EUS
experts as the most realistic and useful for teaching EUS-FNA, but
the least easy to incorporate into fellowship training [18]. These
experts recommended using different learning tools at different
time periods during the learning curve for EUS and EUS-FNA. A
model using porcine organs was preferred over both live pigs
and phantoms devoid of animal material.
4.2. Learning curve of EUS-FNA
Five endosonographers have reported their learning curve for
EUS-FNA of solid pancreatic lesions, the procedure considered to
be the most complex (" Table 2) [13 16]. All endosonographers
had performed a minimum of 132 300 diagnostic EUS prior to
EUS-FNA, and had participated in a formal or informal training
program, and they used ROSE to guide the number of FNA passes.
For the cytopathological diagnosis of pancreatic cancer, sensitiv-
ity increased with the operators experience and reached 80 %
after 20 to 30 EUS-FNA (including operators experience prior to
Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
Guideline 193
Training: type, duration Sensitivity for Complications FNAs needed to
cancer diagnosis: reach 80 %
First vs. last FNA sensitivity for
series compared cancer diagnosis,
n
1
Informal , 2 months 44 % vs. 91 % No data 20
Informal 1, no data 50 % vs. 80 % 0 30
Formal, 1 year 92 % vs. 95 % 13 %2 No data
the study if applicable). ROSE may be useful to guide the number
of FNA passes, learn which parts of the lesion may be targeted for
increased diagnostic yield, and correct technical errors (e. g.,
bloody or paucicellular material) [21, 22].
The American Society of Gastrointestinal Endoscopy has reap-
proved in November 2008 its recommendations that competency
should be assessed separately for pancreatic and non-pancreatic
EUS-FNA, after at least 25 supervised procedures of each type
[16]. For all endoscopy procedures, substantial variations exist
between individuals with regard to the speed of learning [23],
so that this number should be considered to be the minimum be-
fore evaluating the trainee. In addition, as shown by Eloubeidi et
al., the learning curve continues long after EUS fellowship. In a
prospective study evaluating 300 EUS-FNA performed by a single
endosonographer, who had performed 45 supervised procedures
during a training period before the study period, the proportion
of EUS-FNA that required 5 passes significantly decreased after
100 additional procedures and the complication rate decreased
after 200 additional procedures (most of these complications
were graded as minor) [13].
5. Techniques of EUS-FNA
!
Needles for sampling under EUS guidance are available from four
manufacturers (" Table 3). Most models are intended for aspirat-
ing cellular material for cytopathological examination. Tissue
fragments suitable for histopathological examination can be ob-
tained using standard 19G or 22G FNA needles as well as with
dedicated histopathological needles (e. g. Trucut, ProCore). The
following sections discuss various technical issues related to
EUS-FNA and EUS-TCB. For detailed expert instruction on how
to perform step-by-step EUS-FNA and EUS-TCB, readers are refer-
red to other sources [24 26].
5.1. Does the diameter of EUS-FNA needle matter?
For EUS-FNA of pancreatic lesions, the 19G, 22G and 25G needles
are characterized by similar diagnostic yields (Evidence level 1 + )
and safety profiles (Evidence level 1 ). Although 19G needles pro-
vide a higher amount of cellular material than do thinner needles,
and, if technically successful, offer a better diagnostic yield, these
advantages are offset by a higher rate of technical failures in the
case of lesions that need to be punctured from the duodenum (Evi-
194 Guideline

Manufacturer Model Needle type Needle diameter Single-use vs. reusable Table 3 Needles for
endoscopic ultrasound (EUS)-
Boston Scientific
guided sampling.
Expect Aspiration needle 19G, 22G, 25G Single-use
Expect Flex Aspiration needle 19G Single-use
Cook
Echotip Aspiration needle 22G Single-use
Echotip Ultra Aspiration needle 19G, 22G, 25G Single-use
Echotip ProCore 1 Aspiration needle with a core trap 19G, 22G Single-use
QuickCore Core biopsy needle 19G Single-use
EchoBrush 2 Needle with cytology brush 19G Single-use
Mediglobe
Sonotip Pro Control Aspiration needle 19G, 22G, 25G Single-use
Olympus
Power-Shot 3 Aspiration needle 22G Reusable
EZ-Shot 3 Aspiration needle 22G Single-use
EZ-Shot 2 Aspiration needle 19G, 22G, 25G Single-use
EZ-Shot 2 with sideport 4 Aspiration needle with sideport 22G Single-use
1
A newly marketed needle designed with a core trap and reverse bevel technology to increase sampling yield and promote collection of histopathological samples.
2
A modified stylet with a 1 5-mm brush at its end; it is designed to pass through a 19G EUS-FNA needle, for brushing the cyst wall.
3
Compatible exclusively with Olympus endoscopes.
4
A newly marketed needle designed with a sideport to draw tissue from both the tip and side of the needle.

dence level 1 ). Studies comparing EUS-FNA needles of different si-
zes in indications other than pancreatic masses are lacking.
We recommend against using 19G needles for transduodenal biop-
sy (Recommendation grade C).
Most of the studies on EUS FNA have been conducted using 22G
needles. Data on thinner (25G) or larger (19G) needles are lim-
ited. A number of recent studies, including two RCTs, compared
results obtained with needles of various diameters. All these
studies were performed in the setting of pancreatic masses [27
31].
It has been suggested that although thinner needles provide less
cellular material than do larger needles, the specimens from the
former are less contaminated by blood, and thus easier to inter-
pret. In addition, thinner needles may be easier to use because
of greater flexibility, particularly for locations requiring impor-
tant scope bending [30, 31]. This preliminary evidence was only
partly confirmed in further research.
In a small prospective, non-randomized study in 24 patients, the
technical success rate for the 25G needle was significantly higher
than for the 22G needle, but only for tumors located in the unci-
nate process [29].
An RCT in 131 patients found no significant differences between
22G and 25G needles in terms of diagnostic yield for malignancy,
number of needle passes needed to obtain a diagnosis, ease of
needle passage into the mass, and rates of needle malfunction
and of complications [27]. ROSE was used in this study.
Another RCT compared EUS-FNA without ROSE using 19G or 22G
needles in 117 patients [28]. In the intention-to-treat analysis, di-
agnostic accuracy was similar for both needles. However, if tech-
nical failures were excluded (per-protocol analysis), diagnostic
accuracy was higher with the 19G compared to the 22G needle
(95 % vs. 79 %, respectively; P = 0.015). Technical failures were re-
ported only for 19G needles in patients with pancreatic head
masses (in 19 % of cases). The 19G needle provided a higher
amount of cellular material with fewer passes (2.4 vs. 2.8; respec-
tively; P = 0.01). No complications were observed in either group.
5.2. Should suction be applied during EUS-FNA?
Applying continuous suction with a syringe during EUS-FNA im-
proves the sensitivity for the diagnosis of malignancy in patients
with solid masses but not in patients with lymphadenopathy (Evi-
dence level 1 ). We recommend using suction for EUS-FNA of solid
masses/cystic lesions and not using suction for EUS-FNA of lymph
nodes (Recommendation grade C).
Traditionally, suction is applied during EUS-FNA using a syringe
[32]. EUS-FNA without suction has been tested in an attempt to
decrease sample bloodiness and to improve accuracy of micro-
scopic examination. Two RCTs have compared EUS-FNA with or
without suction, in a total of 95 patients with suspected malig-
nant lymph nodes, pancreatic masses or submucosal tumors
(SMTs) [33, 34]. In a study on 46 patients with lymphadenopathy,
applying suction did not improve diagnostic accuracy and wors-
ened specimen bloodiness compared with EUS-FNA without suc-
tion [33]. In the other study, however, using suction during EUS-
FNA of solid masses was associated with a significantly higher
sensitivity for cancer diagnosis (86 % vs. 67 %; P = 0.05) [34]. A pi-
lot trial suggested that applying continuous high pressure suc-
tion (using a balloon inflation device) allowed retrieval of tissue
samples for histopathological examination in most cases [35].
5.3. With or without needle stylet?
Using the needle stylet does not seem to impact EUS-FNA sample
quality and results (Evidence level 1 ). There is insufficient evi-
dence to recommend for or against using the stylet and the decision
in this regard should be left to the discretion of the endosonogra-
pher performing the procedure (Recommendation grade C).
For years the standard approach has been to reinsert the stylet
into the needle before every pass to prevent sample contamina-
tion by cells from the digestive wall as well as blockage of the
needle that would hinder sample aspiration. Recently the value
of this measure has been questioned by the results of three stud-
ies, including one RCT [36 38]. While these studies found no ad-
vantages of using the stylet with regard to the quality of sample
obtained or the diagnostic yield of malignancy, they also did not
demonstrate any disadvantages of this approach. In addition, two
of these studies suffered from significant methodological limita-
tions [37 39].

Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205

5.4. Which part of the lesion should be punctured
to maximize the diagnostic yield?
Diagnostic accuracy of EUS-FNA does not differ depending on
whether the sampling is performed from the edge of a lymph node
or from its center (Evidence level 1 ). No data on this topic are
available for lesions other than lymph nodes.
We recommend sampling all parts of solid lesions or lymph nodes
(Recommendation grade C) and sampling any solid component in-
side pancreatic cysts and the wall of the cyst (Recommendation
grade D).
Because malignant masses and lymph nodes may undergo cen-
tral necrosis, it has been assumed that FNA of the edges of the le-
sion rather than of the center would increase the diagnostic
yield. The study by Wallace et al. in which 46 lymph nodes were
punctured found that aspiration from the edge of the lymph node
did not increase the likelihood of a correct diagnosis when com-
pared to aspiration from the lymph node center [33]. This issue
has not been studied for lesions other than lymph nodes. In prac-
tice, the needle is usually fanned throughout the lesion to sam-
ple all its parts.
Recent research indicates that new techniques such as contrast-
enhanced EUS and elastography may potentially be useful to se-
lect the most suspicious area of a lymph node/tumor for EUS-FNA
[40, 41].
According to expert opinion, the diagnostic yield of EUS-FNA of
pancreatic cysts may be improved by aspirating cells from the
cyst wall after having aspirated cyst fluid. Using this method, Ro-
gart et al. collected cellular material adequate for cytopathologi-
cal assessment in 82 (76.6 %) of 107 cysts [42]. If a cyst wall thick-
ening is present (or solid nodules or a solid component inside the
cyst), it is advised to sample these targets before aspirating cyst
fluid (this would become more difficult once the cyst has col-
lapsed). A cytology brush can also be introduced into the cyst
through a 19G needle to scrape the cyst wall [43 45]. This tech-
nique has been shown to increase the cellular and diagnostic
yields; however, serious concerns exist about its complication,
in particular a high risk of intracystic bleeding [43, 45, 46].
5.5. What is the role of ROSE?
Gross visual inspection is unreliable in assessing the adequacy of
EUS-FNA specimens for cytopathological examination. ROSE pro-
vides a highly reliable diagnosis with an excellent agreement with
the final cytopathological diagnosis (Evidence level 2 + ). There is
limited evidence to suggest that ROSE increases the diagnostic yield
of EUS-FNA and accuracy for malignancy detection (Evidence level
2 ). The diagnostic yield of EUS-FNA with ROSE in most studies ex-
ceeds 90 %; however, similarly good results have been reported from
selected studies without ROSE. (Evidence level 2 + ). Data on cost
effectiveness of ROSE are very limited.
In view of these data, it is felt that implementation of ROSE should
be considered especially during the learning phase of EUS-FNA and
at centers in which specimen adequacy rates are below 90 % (Re-
commendation grade D).
5.5.1. Gross visual inspection of the specimen
In a prospective, double-blind, study that included 37 patients
with a solid pancreatic mass, neither trained EUS technologists
nor cytotechnologists were able to provide a reliable assessment
of specimen adequacy by using gross visual inspection. The
agreement between their assessment and the final microscopic
assessment by a cytopathologist was only fair, with kappa values
of about 0.2. False-positive assessments occurred for about 30 % of
Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
Guideline 195
the slides, with the potential consequence of premature proce-
dure termination [47].
5.5.2. ROSE by a cytopathologist
ROSE has been evaluated mostly in studies of percutaneous FNA:
it is generally accepted that ROSE diagnosis is highly reliable and
ROSE is the critical procedure for reducing the number of inade-
quate diagnoses. In addition, ROSE may reduce costs by decreas-
ing the number of repeat procedures [48 50].
Data on ROSE of EUS-FNA specimens are limited. Based on early
reports that suggested that ROSE may increase adequacy rates of
EUS-FNA specimens by 10 % 29 % [51, 52], ROSE has been imple-
mented at many EUS centers, especially in the United States [53],
and has been used in many important studies on EUS-FNA [54
57]. The very high specimen adequacy rates consistently report-
ed in these studies ( > 90 % 95 %) have been assumed to be linked
to ROSE. However, EUS-FNA with vs. without ROSE has never
been compared in an RCT. In addition, as discussed below, there
are data to suggest that neither does ROSE guarantee, nor is it es-
sential to achieve high adequacy rates.
Evaluating ROSE accuracy or impact has been the primary focus
of a few studies only:
In a prospective study evaluating 607 EUS-FNA procedures
(mostly of pancreatic masses and lymph nodes), the agree-
ment between ROSE and final cytopathological diagnosis was
excellent (kappa = 0.84) [58]. Compared with the true final di-
agnosis, accuracies of ROSE and final cytopathological exami-
nation were not statistically different (93.9 % and 95.8 %,
respectively).
In a retrospective comparison of EUS-FNA results obtained by
one endosonographer in two university hospital centers (with
ROSE available in only one of them), unequivocal cytopatholo-
gical diagnosis was obtained significantly more frequently
(78 % vs. 52 %; odds ratio [OR], 2.94; P = 0.001) with a lower rate
of unsatisfactory specimens (9 % vs. 20 %; OR, 0.36; P = 0.035) at
the center where ROSE was available [21]. Because patient po-
pulations and indications for EUS-FNA significantly differed
between the compared centers, no definite conclusions can be
drawn from this study.
In a prospective multicenter study that evaluated 409 patients,
two centers used ROSE whereas the other two did not [59]. The
results obtained in these two settings were not significantly
different (except for a higher negative predictive value in the
subgroup of patients with extraintestinal mass lesions when
ROSE was used).
In a retrospective analysis of risk factors for inadequate EUS-
FNA specimens in 247 pancreatic tumors and 276 lymph
nodes, cytopathological adequacy was significantly higher for
lymph nodes (96 % vs. 84 %, P = 0.008) but not for pancreatic
tumors (99 % vs. 100 %; P = 1) when an on-site cytotechnologist
was present [60].
A recent retrospective analysis of data from a prospectively
maintained database showed that in patients with solid pan-
creatic masses, ROSE reduced the number of inadequate FNA
samples (1 % vs. 12.6 %; P = 0.002) and improved the sensitivity
(96.2 % vs. 78.2 %; P = 0.002) and overall accuracy (96.8 % vs.
86.2 %; P = 0.013) of EUS-guided FNA for the diagnosis of ma-
lignancy. In addition, a significantly lower number of needle
passes was required when ROSE was used [61]. An important
limitation of this study was that patient allocation to study
groups (95 patients biopsied with and 87 without ROSE) was
196 Guideline
not random but based on whether on-site cytopathology ser-
vice was available on a given day of the week.
Of note, many recent studies in which ROSE was not used report-
ed adequacy rates of > 90 %, indicating that at high volume centers
ROSE is not indispensable to achieve excellent results [60, 62
64]. On the other hand, the use of ROSE does not unconditionally
guarantee EUS-FNA success. In a survey of 21 EUS centers in the
United States, the diagnostic rate for malignancy in patients with
pancreatic tumors varied widely from center to center, despite
the fact that ROSE was used at almost all of them [53].
Little is known on the impact of ROSE on EUS-FNA procedural
time and it remains unclear whether using ROSE prolongs the
procedure or makes it less time-consuming by reducing the
number of needle passes. It is assumed that an average time for
obtaining the specimen and performing on-site examination is
15 min per sample [65]. Average time expenditure by the cytopa-
thologist for ROSE of computed tomography (CT)-guided and ul-
trasound-guided FNA specimens is relatively high (48.7 and 44.4
minutes, respectively; measured from the time the pathologist
left the office to the time the pathologist returned to the office
after the aspiration procedure and interpretation) [66].
5.5.3. ROSE by endosonographers
A prospective double-blind study showed that even endosono-
graphers with special training and extensive experience at re-
viewing cytopathological material alongside a cytopathologist
are less accurate than a cytotechnician in the assessment of speci-
men adequacy (68 % 76 % for three endosonographers vs. 82 %
for a cytotechnician; P = 0.004) and in the diagnosis of malignancy
(69 % 72 % for three endosonographers vs. 89 % for a cytotechni-
cian; P < 0.001) [67].
Another study did not find significant differences in specimen
adequacy rates, number of needle passes or EUS-FNA perform-
ance characteristics in two subsequent 2-year periods in which
ROSE was performed by endosonographers (first period) or cyto-
pathologists (second period). The study evaluated only a total of
73 EUS-FNA procedures [68].
5.6. How many passes should be performed if ROSE
is not used?
Various studies have investigated the adequate number of needle
passes that should be performed if ROSE is not used. Discordant
conclusions have been reached for solid masses, while more concor-
dant results have been reported for lymph nodes, liver lesions, and
pancreatic cysts. We recommend performing 3 needle passes for
lymph nodes and liver lesions, at least 5 needle passes for solid pan-
creatic masses, and a single pass for pancreatic cysts (Recommen-
dation grade C).
The knowledge of the adequate number of needle passes to be
performed to reach a good diagnostic accuracy is of paramount
importance in centers where ROSE is not used. Differences exist
based on the nature of the target lesion.
5.6.1. Pancreatic masses
Erickson et al. found in a large study (95 patients) that a mean of
3.42.2 needle passes (range, 1 10) were required to make a di-
agnosis [52]. Well-differentiated pancreatic adenocarcinomas re-
quired a higher number of passes (5.5 2.7) as compared to mod-
erately (2.7 1.2) and poorly (2.31.1) differentiated tumors. The
authors recommended performing 5 6 needle passes for pan-
creatic masses. In another study of 33 patients (9 with cystic le-
sions), Leblanc et al. found that the sensitivity gradually in-
Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
creased from 16.7 % for the first pass to 86.7 % when more than 7
passes were performed [69]. Pellis Urquiza et al. found in a study
in 102 patients that the accuracy of EUS-FNA for pancreatic mas-
ses reached a plateau at the 4th needle pass [65]. More recently,
Turner et al. reported in a large cohort of 559 patients with a pan-
creatic mass that a diagnostic accuracy of about 80 % could be ob-
tained with only 2 to 3 needle passes [70]. A high yield with a
mean of 1.88 needle passes was also found in another study, in
which the material gathered with a 22-gauge EUS-FNA needle
was first evaluated for the presence of small tissue core samples
that were placed in formalin for histopathological examination
and the rest of the material was sent for cytopathological analysis
[63].
5.6.2. Lymph nodes
Lymph nodes generally require a lower number of needle passes
to obtain an adequate diagnostic accuracy. Apart from the study
by Leblanc et al. who recommended performance of at least 5
needle passes, other studies agreed that 3 needle passes were
sufficient [33, 52, 65, 69].
5.6.3. Submucosal tumors
In the study by Pellis Urquiza et al., the accuracy of EUS-FNA for
intramural lesions in 11 patients increased gradually with each
subsequent pass to reach a plateau at the 45 % level after the
fourth pass [65]. In another study, conducted in 112 patients, a
mean of 5.3 needle passes (range 3 9) was done, with a diagnos-
tic accuracy of 83.9 % when both diagnostic and suspicious sam-
ples were considered to be positive [71]. Differently, in a study
from Japan on 141 patients, a mean of 2.5 0.7 (range 1 5) pas-
ses were performed with an overall rate of sample adequacy of
83 % that was significantly better for lesions greater than 2 cm
than for those with a smaller diameter [72]. In the latter two
studies, multivariate analysis did not show the number of needle
passes to be associated with the adequacy of the collected speci-
mens.
5.6.4. Miscellaneous and liver lesions
The numbers of needle passes recommended for miscellaneous
and liver lesions are similar to those recommended by different
authors for pancreatic masses and lymph nodes, respectively. In
particular, Leblanc et al. found that for miscellaneous lesions the
sensitivity of EUS-FNA increased from 33 % up to 92 % after 7 pas-
ses and did not change with additional passes [69]. For liver le-
sions, Erickson et al. suggested a good diagnostic accuracy with
2 3 needle passes, a number which is in agreement with other
studies [52, 73, 74].
6. Techniques to obtain tissue for histopathological
evaluation
!
Although cytopathological examination of EUS-FNA specimens
allows detection of malignancy, it often cannot provide more
specific information that may be necessary for patient manage-
ment. Potential advantages of tissue specimens include informa-
tion about tissue architecture and more reliable immunostaining.
 Guideline 197

Table 4 Studies in which endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) with standard needles was used to obtain tissue for histopathological
evaluation (EUS-FNA histology).

First author, year (design) Indication for Patients, Needle size Specimen adequate for:
EUS-FNA n Number of
Cytology Histology Either histology or
passes, n
cytology
Moller, 2009 (retrospective) [63] Pancreatic mass 192 22G 93 % 87 % 99 %
1.88 (mean)
Iglesias-Garcia, 2007 (prospective) Pancreatic mass 62 22G 82 % 84 % 90.3 %
[77] 2 + 11
Voss, 2000 (retrospective) [79] Pancreatic mass 99 22G 74 %
2.7 (mean)
Papanikolaou, 2008 (prospective) [76] Various 2 42 22G 62 % 67 % 74 %
2 (median)
Larghi, 2005 (prospective) [35] Various 2 27 22G 96 %
Single pass 3
Turhan, 2010 (prospective) [81] Upper gastrointes- 49 22G 43 %
tinal SMTs 3 (median)
6 19G 100 %
2 (median)
Yoshida, 2009 (unclear whether GIST 49 22G 71 % 63 % 82 %
prospective or retrospective) [75] Not reported
Ando, 2002 (prospective) [82] GIST 23 22G 100 %
2.8 (mean)
Akahoshi, 2007 (prospective) [83] SMT 53 22G 79 %
2.4 (mean)
Yasuda, 2006 (prospective) [78] Lymphadenopathy 104 19G 100 %
2 median
GIST, gastrointestinal stromal tumor; SMT, submucosal tumor.
1
Two passes for cytology plus third pass for histology.
2
Mostly pancreatic mass (30 cases, 71 % [76]; and 17 cases, 63 % [35]).
3
Single pass using continuous high negative pressure suction.

6.1. Should tissue fragments be isolated from EUS-FNA
specimens and processed for histology?
EUS-FNA with standard needles can provide tissue adequate for
histopathological evaluation from most pancreatic tumors (Evi-
dence level 2 + ). Combining EUS-FNA histology and EUS-FNA cytol-
ogy seems to increase EUS-FNA diagnostic yield (Evidence level 2 )
and sensitivity for pancreatic cancer detection (Evidence level 2 + ).
Other potential advantages of EUS-FNA histology consist of facilita-
ted immunostaining and better capability to diagnose specific tu-
mor types (Evidence level 2 ).
We suggest implementation of this technique into routine practice
(Recommendation grade D).
There is accumulating evidence that tissue adequate for histopa-
thological assessment can be obtained using standard EUS-FNA
in a significant proportion of cases [63, 75 79]. This technique
(EUS-FNA histology) involves gross visual inspection of the sam-
ple to collect minute tissue fragments that are subsequently pro-
cessed for histopathological examination (see section 7.3, below).
EUS-FNA histology has been evaluated mostly in the setting of
pancreatic tumors, submucosal tumors (SMTs) and lymphadeno-
pathy of unknown origin ( " Table 4).
6.1.1. Pancreatic mass
Tissue adequate for histopathological evaluation can be obtained
from 67 % 86.5 % of pancreatic masses using a single pass or few
needle passes with a standard 22G needle [63, 76, 77, 79, 80].
Combining EUS-FNA cytology and histology significantly increas-
es the sensitivity for malignancy diagnosis compared to cytology
or histology alone (82.9 % vs. 68.1 % for cytology [P = 0.007], and
60 % for histology [P < 0.0001]) [63]. FNA histology also showed a
trend towards higher accuracy in diagnosing specific tumor
types other than adenocarcinoma.
6.1.2. Submucosal tumors
Comparative data are lacking, but studies that used EUS-FNA his-
tology alone or combined with EUS-FNA cytology reported a
higher diagnostic yield than studies that relied only on cytopa-
thological preparations (cell blocks and especially smears) [75,
81 83].
6.1.3. Lymphadenopathy of unknown origin
In a series of 104 patients with mediastinal or/and abdominal
lymphadenopathy of unknown origin, a specimen adequate for
histopathological evaluation was obtained in all cases using a
19G needle [78]. Among 50 patients with a diagnosis of lympho-
ma, subtyping was possible in 88 % of cases.
6.2. What is the role of EUS-guided Trucut biopsy?
Transduodenal EUS-TCB is characterized by a very high failure rate
(Evidence level 2 + ). For non-transduodenal routes, the failure rate
is low and the accuracy for the detection of malignancy is similar to
that of EUS-FNA (Evidence level 2 + ). The accuracy of dual sampling
(EUS-TCB + EUS-FNA) is superior to either technique alone (Evi-
dence level 2 + ). Sequential sampling (EUS-TCB with EUS-FNA res-
cue) has similar accuracy to that of dual sampling (Evidence level
2 ). EUS-TCB is superior to EUS-FNA in establishing some specific
diagnoses, especially benign tumors or if immunostaining is requir-
ed (Evidence level 2 ).

Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
198 Guideline

Table 5 Studies directly comparing endoscopic ultrasound (EUS)-guided Trucut biopsy (TCB) with EUS-guided fine needle aspiration (FNA) for detection of
malignancy.

First author, year (design) Indications for biopsy Patients, n Diagnostic accuracy for malignancy
(Sampling route)
EUS-TCB EUS-FNA1 EUS-FNA + EUS-TCB
Gerke, 2010 (prospective RCT) [90] Various 44 /36 2 88 % 78 %
(Transesophageal, transgastric,
transrectal)
Sakamoto, 2009 (prospective) [29] Pancreatic mass 24 50 % 79 %
(Transgastric, transduodenal)
Kipp, 2009 (retrospective) [94] Mediastinal/abdominal lesion 86 77 % 70 % 87 %
(Not reported)
Storch, 2008 (retrospective) [87] Mediastinal/thoracic lesions 48 79 % 79 % 98 %
(Transesophageal)
Shah, 2008 (retrospective) [95] Pancreatic mass 123 3 89 % 96 %
(Transgastric)
Aithal, 2007 (prospective) [84] Various 95 89 % 82 % 93 %
(Transesophageal, transgastric)
Saftoiu, 2007 (prospective) [86] Mediastinal masses 30 68 % 74 %
(Transesophageal)
Wittmann, 2006 (prospective) [64] Various 159 4 73 % 77 % 91 %
(Transesophageal, transgastric)
Storch, 2006 (retrospective) [88] Various 41 76 % 76 % 95 %
(Transesophageal, transgastric)
RCT, randomized controlled trial
1
EUS-FNA was performed using 22G needles in all studies. Rapid on-site cytopathological evaluation was used only in the study by Kipp et al. In the study by Gerke et al. a single pass
using high-negative suction was performed for EUS-FNA.
2
44 and 36 patients in EUS-TCB and EUS-FNA groups, respectively.
3
72 patients had only EUS-FNA and 51 patients had both EUS-FNA and EUS-TCB.
4
63 patients with lesions < 2 cm had only EUS-FNA and 96 patients with lesions 2 cm had both EUS-FNA and EUS-TCB.

In most instances EUS-TCB does not offer advantages over EUS-
FNA; however, EUS-TCB should be considered when tissue architec-
tural details and immunostaining are required to establish a specif-
ic diagnosis (Recommendation grade C).
There is much less experience with EUS-TCB than with EUS-FNA,
with around 1250 EUS-TCB procedures reported to date from a
few centers. The 19G Quick Core needle, the only needle available
for EUS-TCB, is relatively stiff and prone to malfunction when
biopsy is attempted in positions that require scope flexion, espe-
cially from the duodenum. For that reason most studies excluded
patients in whom a transduodenal approach was required. The
few studies in which transduodenal EUS-TCB was attempted
reported consistently very low technical success rates, ranging
between 8 % and 40 % in consecutive patients [29, 84, 85]. In
addition, most studies included only patients with target lesions
20 mm [54, 86 89].
Adequacy rates reported for non-transduodenal EUS-TCB are
racy of such an approach was similar to that obtained with dual
sampling [84]. Rescue EUS-FNA was necessary only in 10 % 11 %
of cases in which EUS-TCB failed [84, 91]. A reverse approach
(EUS-FNA with EUS-TCB rescue) has not been evaluated.
Although not superior to EUS-FNA in detecting malignancy, EUS-
TCB offers advantages in establishing some specific diagnoses, in
particular of benign diseases [86, 87, 93]. Limited evidence sug-
gests that immunostaining studies can be performed more reli-
ably on EUS-TCB than on EUS-FNA samples [89]. Promising re-
sults have been reported from studies evaluating EUS-TCB in con-
ditions in which the diagnosis relies mostly on tissue architectur-
al details and EUS-FNA with cytopathological examination has
limited value (autoimmune pancreatitis, non-focal chronic pan-
creatitis, tuberculosis and sarcoidosis, liver parenchymal disease,
lymphoma) [96 100].
The feasibility and yield of sampling with a new histology needle
(Echotip ProCore 19G; " Table 3) were recently evaluated in a

much higher (83 % 100 % in prospective studies) [29, 64, 84 86,
90 93]. In the largest series published an adequate sample was
obtained in 215 of 239 patients (90 %), with a median of 3 needle
passes [93].
In an RCT that compared EUS-TCB vs. EUS-FNA using high nega-
tive pressure, the former method provided core specimens more
frequently (95.3 % vs. 27.8 %; P < 0.0001); however, this fact did
not translate into better diagnostic accuracy (88.3 % vs. 77.8 %; P
= 0.24) [90]. Also other studies that directly compared EUS-TCB
and EUS-FNA found no significant difference between these
methods in the accuracy for malignancy detection ( " Table 5)
[29, 64, 84, 86 88, 90, 94, 95]. Dual sampling (EUS-FNA + EUS-
TCB) was consistently shown to improve accuracy when compar-
ed to either technique alone. Because using two needles in one
patient is impractical and costly, a sequential approach has been
evaluated that involved EUS-TCB with EUS-FNA rescue. The accu-
multicenter study involving 109 consecutive patients with 114
lesions (pancreatic masses, lymph nodes and other indications)
[101]. Biopsy was successful in all but two cases (98 %). A sample
adequate for histopathological evaluation was obtained from 89 %
lesions. In the remaining 9 % of cases the sample was adequate for
cytopathological evaluation (cell blocks). Sensitivity, specificity,
positive predictive value, negative predictive value, and overall
accuracy for diagnosis of malignancy were 90.2 %, 100 %, 100 %,
78.9 %, and 92.9 %, respectively. No complications were observed.
Of note, transduodenal biopsy was successful in 33 of 35 conse-
cutive cases (94 %) which seems to be an important advantage
over EUS-TCB. However, direct comparisons of the ProCore nee-
dle with other needle types are lacking.

Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205

7. Specimen processing
! Cell block is a preparation in which the specimen is centrifuged
No adequate study has compared direct smear cytology vs. liquid-
based cytology (LBC) for processing specimens collected with EUS-
FNA. Similarly, no study has evaluated which of the methods de-
scribed for collecting tissue fragments for histopathological exami-
nation is better. In the case of suspected tuberculosis or lymphoma,
polymerase chain reaction (suspected tuberculosis) on histopatho-
logical specimens and flow cytometry (suspected lymphoma), after
placement of the collected specimen in an adequate transport
medium, have been shown to significantly increase the diagnostic
yield (Evidence level 2 + ). The specific method to be used for both
cytopathological processing and collection of histopathological spe-
cimens should be left to the discretion of each center, depending on
their confidence with available methods (Recommendation grade
D). Cell blocks can be used as a complement to rather than a repla-
cement for smears or LBC (Recommendation grade D). If tuberculo-
sis is suspected, then polymerase chain reaction should be used; if
lymphoma is suspected, then flow cytometry should be used (Re-
commendation grade C).
Because EUS-FNA accuracy may be compromised by inadequate
specimens, appropriate processing of samples is crucial. Al-
though a direct smear has traditionally been used for preparing
EUS-FNA specimens, other methods are available including LBC,
cell block preparation, and EUS-FNA histology.
7.1. Smears
Smears may be prepared using the conventional direct smear
method or the LBC method. Direct smears are prepared in the en-
doscopy suite by extruding the needle content onto a glass slide
and spreading the material in an evenly thin way. This technique
requires a certain level of skill and practice to avoid common pit-
falls, including a smear that is too thick (cells obscured within
clusters) and air-drying artifacts [102 104]. For detailed instruc-
tion, readers are referred to recent guidelines [48].
Smears may be allowed to dry or be fixed immediately by spray
fixation or immersion into 95 % alcohol. Unfixed smears are a po-
tential biohazard and should be handled accordingly [48]. Air-
dried and alcohol-fixed direct smears are usually stained using
Giemsa and Papanicolaou methods, respectively. Needle wash-
ings, preserved in a liquid transport medium, provide additional
material for further studies including special stains, immunocy-
tochemistry, microbiological investigations, flow cytometry, or
molecular testing [48].
For LBC, the aspirate is transferred into a vial containing a fixative
or a transport medium. Smears are then prepared in the labora-
tory. Importantly, the remainder of the samples should be stored
so that it is available for additional preparation that may prove
useful after initial cytopathological examination. The various
available LBC methods have not been compared in EUS-FNA stud-
ies. Therefore, the specific method used should be at the discre-
tion of each pathology laboratory. Thin-layer LBC is an automated
process designed to overcome the problems associated with
manual preparation of smears described above. This technique
has mostly been evaluated in cervical cytology and shown to be
equivalent or superior to conventional smear methods in this set-
ting [105]. Data on the use of thin-layer LBC preparations for EUS-
FNA aspirates are limited and contradictory [22, 104, 106 108].
Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
Guideline 199
7.2. Cell block
into a pellet, formalin-fixed, paraffin-embedded, and sectioned
for standard staining or ancillary tests such as immunocytochem-
istry and genetic analysis. Cell blocks can be prepared from left-
over material rinsed from the needle after preparation of smears
or from material especially obtained for this purpose (by alternat-
ing drops of the aspirate for smears and for cell blocks or by per-
forming additional needle passes) [102]. Cell blocks are used as a
complement to rather than a replacement for smears.
7.3. Specimen processing for histology
Methods described for collecting tissue fragments for histopatho-
logical examination from specimens obtained with standard
EUS-FNA needles include injection of 2 ml saline through the
needle to expel the specimen directly into a fixative [77, 79], or
expelling the specimen with the needle stylet onto a glass slide
or into saline and picking up tissue fragments to immerse them
into a fixative [63, 75]. Tumor tissue is usually whitish; however,
red coagula may also contain tumor tissue [63, 75, 78]. Gross vis-
ual inspection seems to be a relatively reliable way to confirm
that the specimen is adequate for histology; however, false-posi-
tive misinterpretation occurs in about 13.5 % 33 % of cases
[63, 76]. Mean length of the core specimens obtained with EUS-
FNA is 6.5 5.3 mm (range 1 22 mm) [77]. Collecting tissue frag-
ments for EUS-FNA histology does not seem to interfere with fur-
ther cytopathological evaluation of the remaining specimen [63,
76, 80].
Tissue obtained with EUS-TCB is usually carefully retrieved with a
thin injection needle from the specimen notch of the Trucut nee-
dle and then placed in buffered formalin and processed in the
same way as forceps biopsy specimens. Median length of core
specimens obtained with EUS-TCB is 10 mm (range 2 18); one
third of samples are fragmented [93]. Special care should be tak-
en not to lose those tiny specimens during processing.
7.4. Special handling
In cases of suspected mycobacterial infection, microbiological
confirmation should be obtained before treatment. Therefore,
the material from one needle pass should be reserved for specific
analysis and adequately fixed according to local protocols. Poly-
merase chain reaction can be performed on paraffin-embedded
material obtained with EUS-guided biopsy to detect mycobacter-
ia if the diagnosis was not suspected initially [109, 110]. Similarly,
in the case of suspected lymphoma, a specimen should be placed
in a transport medium adequate for flow cytometry, which has
been reported to significantly increase the yield for the diagnosis
of lymphoma [111, 112].
8. Complications of EUS-FNA and their prevention
!
EUS-FNA is a safe procedure with a complication rate of approxi-
mately 1 % (Evidence level 2 + + ). Complications include infection,
bleeding, and acute pancreatitis; they are more frequent for EUS-
FNA of cystic compared with solid lesions (Evidence level 2 ). Bac-
teremia is rare after EUS-FNA, including that of perirectal and rec-
tal lesions (Evidence level 2 + + ). The 19G, 22G, and 25G EUS-FNA
needles present similar complication rates. Transesophageal and
transgastric EUS-TCB have similar safety profiles compared with
EUS-FNA, at least in experienced hands (Evidence level 1 ). Aspir-
in/non-steroidal anti-inflammatory drugs (NSAIDs) do not seem to
200 Guideline

Table 6 Complications of endoscopic ultrasound (EUS)-guided fine needle aspiration (FNA) in selected prospective series.

First author, year Patients, n Follow-up, Lost to Morbidity, Complications after EUS-FNA of: Procedure-related
days follow-up, % % mortality, %
Fluid collec- Solid masses
tions
Al-Haddad, 2008 [114] 483 30 14 1.4 3 /831 4 /400 0
Bournet, 2006 [115] 213 2 1 0 2.2 1 /74 1 4 /139 0
Eloubeidi, 2006 [117] 355 3 1 2.5 0 /0 9 /355 0
Mortensen, 2005 [113] 567 2 No data No data 0.4 0 /33 1 2 /534 0.2
Williams, 1999 [57] 333 No data No data 0.3 1 /20 1 0 /313 0
Bentz, 1998 [116] 60 No data No data 0 No data No data 0
Wiersema, 1997 [59] 457 30 0 1.1 3 /22 2 /435 0
1
Antibiotic prophylaxis administered.
2
Patients with EUS-guided interventions other than fine needle aspiration were not included in the table.

increase the risk of bleeding following EUS-FNA (Evidence level
2 ).
Antibiotic prophylaxis is recommended before EUS-guided sam-
pling of cystic lesions (Recommendation grade C) but not of solid
lesions (Recommendation grade B). Antibiotic prophylaxis of infec-
tive endocarditis is not recommended (Recommendation grade B).
Coagulation check-up is recommended before EUS-FNA only in pa-
tients with a personal or family history suggesting bleeding disor-
der or with a clear clinical indication (Recommendation grade C).
EUS-guided sampling should not be performed in patients treated
with oral anticoagulants (Recommendation grade C) or thienopyr-
idines (Recommendation grade D). In addition, treatment with as-
pirin or NSAIDs is a contraindication for EUS-guided sampling of
cystic lesions (Recommendation grade C).
EUS-TCB is contraindicated for lesions requiring a transduodenal
approach, and lesions < 20 mm or of cystic appearance, and when
the operator has limited experience with standard EUS-FNA (Re-
commendation grade D).
8.1. What is the overall risk of complications associated
with EUS-FNA?
EUS-FNA morbidity reported in the prospective series listed in
" Table 6 ranged between 0 and 2.5 % (1.2 % in pooled material
(22G vs. 25G, and 19G vs. 25G) recorded no complications at all
[27, 28]. In another study, the number of needle passes was not
associated with the risk of complications [119]. Given the very
low risk of EUS-FNA complications, these studies were clearly un-
derpowered to detect a significant difference.
EUS-TCB presents a safety profile similar to that of EUS-FNA, at
least in experienced hands. It has to be noted, however, that be-
cause of the limited flexibility of the Trucut needle, in most stud-
ies EUS-TCB was not performed transduodenally. In addition,
only lesions 2 cm were usually punctured. An RCT of 77 patients
who underwent either EUS-TCB or EUS-FNA (using a 22G needle
and high suction pressure) found similar complication rates in
both groups (2.3 % vs. 2.8 %) [90]. Similar complication rates
(1 % 2.4 %) were reported in two large prospective series of
EUS-TCB including 96 and 247 patients, respectively [64, 93].
The latter study suggested that operator experience might be an
important factor because all complications were observed among
the first 100 patients [93]. Selected small studies have reported
higher morbidity rates (4 % 12.5 %, including complications re-
quiring surgery) [26, 96,120].
8.3. Specific complications and their prevention

from all studies); there was one death among 2468 patients
(0.04 %) [57, 59 ,113 117]. Complications mostly included infec-
tion, bleeding, and acute pancreatitis. Retrospective series tend
to under-report complications [118].
8.2. What are the risk factors for EUS-FNA complications?
Because complications associated with EUS FNA are very rare,
studies would require very large numbers of patients to be ade-
quately powered to evaluate risk factors for complications.
Wiersema et al. reported a significantly higher incidence of com-
plications for EUS-FNA of pancreatic fluid collections than for
pancreatic solid lesions (3 /22 [14 %] vs. 2 /452 [0.5 %], respective-
ly; P < 0.001). The complications observed after FNA of fluid col-
lections included two febrile episodes and one pseudocyst he-
morrhage; two of these patients required surgery [59]. In all sub-
sequent studies ( " Table 6), antibiotic prophylaxis was adminis-
tered before EUS-FNA of pancreatic fluid collections, but in spite
of that the overall morbidity remained higher than for solid mas-
ses (5 /210 [2.4 %] vs. 10 /1386 [0.7 %], respectively). Based on
these data, a cystic character of the lesion is considered a risk fac-
tor for complications, both of infection and bleeding.
A larger needle size does not seem to be associated with a higher
complication risk. Two RCTs comparing needles of different sizes
8.3.1. Infection
The incidence of bacteremia following EUS-FNA, including EUS-
FNA of rectal and perirectal lesions, is low (0 % 6 %) and similar
to that observed after EUS without FNA [121 124]. According to
recent guidelines, antibiotic prophylaxis is not recommended for
the prevention of infective endocarditis in patients with cardiac
risk factors who undergo EUS-FNA [125, 126].
Clinical infectious complications after EUS-FNA of solid lesions
(including rectal and perirectal lesions) are very rare, with inci-
dences of 0 % to 0.6 % in large prospective series [57, 59, 113
115, 117, 123]. As discussed above it is generally accepted that
the higher risk of EUS-FNA in fluid collections warrants antibiotic
prophylaxis. Fluoroquinolones administered intravenously be-
fore the procedure and orally for 3 5 days thereafter are prob-
ably the regimen used most commonly [114, 125]; betalactam
antibiotics have also been used in this setting [115, 119]. The in-
cidence of infectious complications in prospective studies that
used prophylaxis was low (0 % to 1.4 %) [57, 113 115]. In a large
retrospective analysis of 603 patients with 651 pancreatic cysts, a
single patient (0.2 %) developed infection [127].
EUS-FNA of mediastinal cysts may be complicated by infection,
including life-threatening mediastinitis [26, 128, 129]. For that
reason, and because of limited clinical impact, EUS-FNA of simple

Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205

mediastinal cystic lesions is usually considered to be contraindi-
cated [130, 131]. On the other hand, EUS-FNA might be of value in
atypical/complex mediastinal cystic lesions to rule out malignan-
cy. In such cases antibiotic prophylaxis should be administered
[132].
8.3.2. Bleeding
Clinically significant bleeding is a possible, but very rare compli-
cation of EUS-FNA. Only single cases have been reported, includ-
ing one that was fatal [113]. The incidence reported in large pro-
spective series ranged between 0 % and 0.5 % [57, 59, 113 115,
117]. Self-limited intraprocedural bleeding with no clinical con-
sequences is more common. Extraluminal bleeding (visible as an
expanding echopoor region adjacent to the sampled lesion) has
been reported to occur during 1.3 % 2.6 % of procedures [133,
134], and intracystic bleeding (gradually expanding hyperechoic
area within the cyst) during 6 % of EUS-FNA of pancreatic cysts
[135]. In both instances the management consisted in cessation
of further needle passes, observation by EUS, and a short course
of antibiotics to prevent infection [133, 135]. The clinical course
has been uneventful in all cases. Rare cases of intraprocedural lu-
minal bleeding requiring intervention (adrenaline injection and
hemostatic clips) have been described [134]. The true effective-
ness of the above measures used in the management of extra-
luminal or intraluminal bleeding related to EUS-FNA has not
been investigated.
Although not evidence-based, platelet count and coagulation
check-up are performed before EUS-FNA in most centers, with
platelet count < 50000 /mm3 and international normalized ratio
> 1.5 considered to be contraindications to EUS-guided sampling
[43, 114, 130, 136]. Criticisms of this approach include poor sensi-
tivity and specificity for the prediction of postintervention bleed-
ing, costs, and the risk that it might indeed increase rather than
decrease the risk of litigation [137]. Recent guidelines recom-
mend the taking of a bleeding history including detail of family
history, previous excessive post-traumatic or postsurgical bleed-
ing and use of antithrombotic drugs, and performance of coagu-
lation testing only in patients with a positive history or a clear
clinical indication (e. g., liver disease) [137].
Data on EUS-guided sampling in patients undergoing treatment
with antithrombotic agents are limited. A prospective controlled
study found no increased bleeding risk following EUS-FNA in 26
patients taking aspirin or NSAIDS when compared to 190 con-
trols (overall bleeding rates of 0 % and 3.7 % respectively) [134].
Two of six patients (33 %) on a prophylactic dose of low-molecu-
lar weight heparin (LMWH) had clinically non-significant bleed-
ing episodes. Based on these data, and according to published
guidelines, the authors recommended that if EUS-guided sam-
pling has to be performed in a patient on LMWH, the procedure
should be performed 8 hours or more after administration of the
drug [134, 138]. No data on the risk of EUS-guided sampling in
patients treated with thienopyridines are available.
EUS-guided sampling should not be performed in patients taking
oral anticoagulants [139]. According to a recently issued ESGE
guideline on endoscopy and antiplatelet agents (APA), EUS-FNA
of solid masses can be performed in patients taking aspirin or
NSAIDS, but not in patients taking thienopyridines (e. g. clopido-
grel). EUS-FNA of cystic lesions should not be performed in pa-
tients taking APA of any kind [140]. If a change in antithrombotic
therapy is required for performance of EUS-FNA, the throm-
boembolic risk in a given patient and the risk-to-benefit ratio
should be considered (for details on the management of antith-
Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
Guideline 201
rombotic agents for endoscopic procedures, readers are referred
to specific guidelines) [139, 140].
8.3.3. Acute pancreatitis
The reported incidence of acute pancreatitis after EUS-FNA of
pancreatic lesions ranged from 0.26 % in a large multicenter sur-
vey study to 2 % in a prospective study that specifically searched
for this complication in 100 consecutive patients [117, 118, 134,
141]. Among the 14 cases analyzed in the multicenter survey,
pancreatitis was mild, moderate, and severe in 10 (71 %), 3 (21
%), and 1 (7 %) case, respectively. The median duration of hospita-
lization for treatment of pancreatitis was 3 days (range 1 21
days). One patient (7 %) with multiple comorbid conditions died
as a result of pancreatitis [118]. Factors suggested to predispose
to post-EUS-FNA pancreatitis included a history of recent pan-
creatitis and puncture of a benign pancreatic lesion; however, a
significant relationship was not demonstrated [118, 141].
8.3.4. Other complications
Less frequent complications include esophageal or duodenal per-
foration [59, 113, 115], bile peritonitis after FNA of obstructed bile
ducts or the gallbladder [142], and seeding of tumorous cells
along the needle tract [143, 144]. The rate of cervical esophagus
perforation at the time of intubation with a curvilinear echoen-
doscope is 0.06 %, as assessed in a large prospective study [145].
The perforation risk is higher in stenotic tumors and aggressive
attempts at passing the stenosis with the endoscope should be a-
voided [113]. Bile peritonitis frequently requires surgery and has
been reported after inadvertent biliary puncture during EUS-FNA
aggravated by subsequent endoscopic retrograde cholangiopan-
creatography [142]. Three cases of tumor seeding following
EUS-FNA have been reported to date [144, 146, 147]; a retrospec-
tive study suggests that peritoneal carcinomatosis related to pan-
creas cancer may occur more frequently after percutaneous com-
pared to EUS-guided FNA [148].
Note
!
ESGE guidelines represent a consensus of best practice based on
the available evidence at the time of preparation. They may not
apply in all situations and should be interpreted in the light of
specific clinical situations and resource availability. Further con-
trolled clinical studies may be needed to clarify aspects of these
statements, and revision may be necessary as new data appear.
Clinical consideration may justify a course of action at variance
to these recommendations. ESGE guidelines are intended to be
an educational device to provide information that may assist en-
doscopists in providing care to patients. They are not rules and
should not be construed as establishing a legal standard of care
or as encouraging, advocating, requiring, or discouraging any
particular treatment.
Alberto Larghi and Marc Giovannini have received research sup-
port from Cook Endoscopy Inc., Limerick, Ireland.
202 Guideline
Institutions
1
Department of Gastroenterology and Hepatology, Medical Centre for Post-
graduate Education and Department of Gastroenterology, The M. Sklodows-
ka-Curie Memorial Cancer Center and Institute of Oncology, Warsaw, Poland
2
Digestive Endoscopy Unit, Universita Cattolica del Sacro Cuore, Rome, Italy
3
CHU Mont-Godinne, Universit catholique de Louvain, Yvoir, Belgium
4
Department of Digestive Endoscopy, Hpital Saint Joseph, Marseille, France
5
Endoscopic Unit, Paoli-Calmettes Institut, Marseille, France
6 intestinal endoscopy: live and simulated. World J Surg 2010; 34:
Department of Gastroenterology, Hpital Priv Jean Mermoz, Lyon, France
7 1764 1770
Service of Gastroenterology and Hepatology, Geneva University Hospitals,
Geneva, Switzerland
Acknowledgment
! guided trucut needle biopsies of perigastric organs. Gastrointest En-
The authors thank Dr. Genevive Ranchin-Monges for helpful
comments.
References
1 Dumonceau JM, Polkowski M, Larghi A et al. Indications, results and
clinical impact of endoscopic ultrasound (EUS)-guided sampling in
gastroenterology: European Society of Gastrointestinal Endoscopy
(ESGE) Clinical Guideline. Endoscopy 2011; 43: 897 912
2 Dumonceau JM, Riphaus A, Aparicio JR et al. European Society of Gas-
trointestinal Endoscopy, European Society of Gastroenterology and
Endoscopy Nurses and Associates, and the European Society of Anaes-
thesiology Guideline: Non-anesthesiologist administration of propofol
for GI endoscopy. Endoscopy 2010; 42: 960 974
3 Dumonceau JM, Andriulli A, Deviere J et al. European Society of Gastro-
intestinal Endoscopy (ESGE) Guideline: prophylaxis of post-ERCP pan-
creatitis. Endoscopy 2010; 42: 503 515
4 Harbour R, Miller J. A new system for grading recommendations in evi-
dence based guidelines. BMJ 2001; 323: 334 336
5 Chang KJ. EUS-guided FNA: the training is moving. Gastrointest Endosc
2004; 59: 69 73
6 Barthet M, Gasmi M, Boustire C et al. EUS training in a live pig model:
does it improve echo endoscope hands-on and trainee competence?
Endoscopy 2007; 39: 535 539
7 Rsch T. State of the art lecture: endoscopic ultrasonography: training
and competence. Endoscopy 2006; 38: 69 72
8 Savides TJ, Fisher AH, Gress FG et al. 1999 ASGE endoscopic ultrasound
survey. Gastrointest Endosc 2000; 52: 745 750
9 Wasan SM, Kapadia AS, Adler DG. EUS training and practice patterns
among gastroenterologists completing training since 1993. Gastroin-
test Endosc 2005; 62: 914 920
10 Ho KY. Survey of endoscopic ultrasonographic practice and training in
the Asia-Pacific region. J Gastroenterol Hepatol 2006; 21: 1231 1235
11 Das A, Mourad W, Lightdale CJ et al. An international survey of the clin-
ical practice of EUS. Gastrointest Endosc 2004; 60: 765 770
12 Maffei M, Dumortier J, Dumonceau JM. Self-training in unsedated
transnasal EGD by endoscopists competent in standard peroral EGD:
prospective assessment of the learning curve. Gastrointest Endosc
2008; 67: 410 418
13 Eloubeidi MA, Tamhane A. EUS-guided FNA of solid pancreatic masses:
a learning curve with 300 consecutive procedures. Gastrointest Endosc
2005; 61: 700 708
14 Mertz H, Gautam S. The learning curve for EUS-guided FNA of pancre-
atic cancer. Gastrointest Endosc 2004; 59: 33 37
15 Harewood GC, Wiersema LM, Halling AC et al. Influence of EUS training
and pathology interpretation on accuracy of EUS-guided fine needle
aspiration of pancreatic masses. Gastrointest Endosc 2002; 55: 669
673
16 Eisen GM, Dominitz JA, Faigel DO et al. Guidelines for credentialing and
granting privileges for endoscopic ultrasound. Gastrointest Endosc
2001; 54: 811 814
17 Sorbi D, Vazquez-Sequeiros E, Wiersema MJ. A simple phantom for
learning EUS-guided FNA. Gastrointest Endosc 2003; 57: 580 583
18 Matsuda K, Tajiri H, Hawes RH. How shall we experience EUS and EUS-
FNA before the first procedure? The development of learning tools.
Dig Endosc 2004; 16: 236 239
19 Bussen D, Sailer M, Fuchs KH et al. A teaching model for endorectal ul-
trasound-guided biopsy and drainage of pararectal tumors. Endoscopy
2004; 36: 217 219
20 Bhutani MS, Aveyard M, Stills HF. Improved model for teaching inter-
ventional EUS. Gastrointest Endosc 2000; 52: 400 403
Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
21 Klapman JB, Logrono R, Dye CE et al. Clinical impact of on-site cytopa-
thology interpretation on endoscopic ultrasound-guided fine needle
aspiration. Am J Gastroenterol 2003; 98: 1289 1294
22 LeBlanc JK, Emerson RE, Dewitt J et al. A prospective study comparing
rapid assessment of smears and ThinPrep for endoscopic ultrasound-
guided fine-needle aspirates. Endoscopy 2010; 42: 389 394
23 Sarker SK, Albrani T, Zaman A et al. Procedural performance in gastro-
24 Vilmann P, Saftoiu A. Endoscopic ultrasound-guided fine needle aspira-
tion biopsy: equipment and technique. J Gastroenterol Hepatol 2006;
21: 1646 1655
25 Wiersema MJ, Levy MJ, Harewood GC et al. Initial experience with EUS-
dosc 2002; 56: 275 278
26 Varadarajulu S, Fraig M, Schmulewitz N et al. Comparison of EUS-guid-
ed 19-gauge Trucut needle biopsy with EUS-guided fine-needle as-
piration. Endoscopy 2004; 36: 397 401
27 Siddiqui UD, Rossi F, Rosenthal LS et al. EUS-guided FNA of solid pancre-
atic masses: a prospective, randomized trial comparing 22-gauge and
25-gauge needles. Gastrointest Endosc 2009; 70: 1093 1097
28 Song TJ, Kim JH, Lee SS et al. The prospective randomized, controlled
trial of endoscopic ultrasound-guided fine-needle aspiration using
22G and 19G aspiration needles for solid pancreatic or peripancreatic
masses. Am J Gastroenterol 2010; 105: 1739 1745
29 Sakamoto H, Kitano M, Komaki T et al. Prospective comparative study
of the EUS guided 25-gauge FNA needle with the 19-gauge Trucut nee-
dle and 22-gauge FNA needle in patients with solid pancreatic masses.
J Gastroenterol Hepatol 2009; 24: 384 390
30 Yusuf TE, Ho S, Pavey DA et al. Retrospective analysis of the utility of en-
doscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in pan-
creatic masses, using a 22-gauge or 25-gauge needle system: a multi-
center experience. Endoscopy 2009; 41: 445 448
31 Itoi T, Itokawa F, Kurihara T et al. Experimental endoscopy: objective
evaluation of EUS needles. Gastrointest Endosc 2009; 69: 509 516
32 Bhutani MS, Suryaprasad S, Moezzi J et al. Improved technique for per-
forming endoscopic ultrasound guided fine needle aspiration of lymph
nodes. Endoscopy 1999; 31: 550 553
33 Wallace MB, Kennedy T, Durkalski V et al. Randomized controlled trial
of EUS-guided fine needle aspiration techniques for the detection of
malignant lymphadenopathy. Gastrointest Endosc 2001; 54: 441 447
34 Puri R, Vilmann P, Sftoiu A et al. Randomized controlled trial of endo-
scopic ultrasound-guided fine-needle sampling with or without suc-
tion for better cytological diagnosis. Scand J Gastroenterol 2009; 44:
499 504
35 Larghi A, Noffsinger A, Dye C et al. EUS-guided fine needle tissue acqui-
sition by using high negative pressure suction for the evaluation of so-
lid masses: a pilot study. Gastrointest Endosc 2005; 62: 768 774
36 Rastogi A, Wani S, Gupta N et al. A prospective, single-blind, random-
ized, controlled trial of EUS-guided FNA with and without a stylet.
Gastrointest Endosc 2011; 74: 58 64
37 Wani S, Gupta N, Gaddam S et al. A comparative study of endoscopic ul-
trasound guided fine needle aspiration with and without a stylet. Dig
Dis Sci 2011; 56: 2409 2414
38 Sahai AV, Paquin SC, Garipy G. A prospective comparison of endo-
scopic ultrasound-guided fine needle aspiration results obtained in
the same lesion, with and without the needle stylet. Endoscopy 2010;
42: 900 903
39 Dumonceau JM. Should we discard the needle stylet during EUS-FNA?
Endoscopy 2011; 43: 167
40 Napoleon B, Alvarez-Sanchez MV, Gincoul R et al. Contrast-enhanced
harmonic endoscopic ultrasound in solid lesions of the pancreas: re-
sults of a pilot study. Endoscopy 2010; 42: 564 570
41 Giovannini M, Thomas B, Erwan B et al. Endoscopic ultrasound elasto-
graphy for evaluation of lymph nodes and pancreatic masses: a multi-
center study. World J Gastroenterol 2009; 15: 1587 1593
42 Rogart JN, Loren DE, Singu BS et al. Cyst wall puncture and aspiration
during EUS-guided fine needle aspiration may increase the diagnostic
yield of mucinous cysts of the pancreas. J Clin Gastroenterol 2011; 45:
164 169
43 Al-Haddad M, Gill KR, Raimondo M et al. Safety and efficacy of cytology
brushings versus standard fine-needle aspiration in evaluating cystic
pancreatic lesions: a controlled study. Endoscopy 2010; 42: 127 132

44 Thomas T, Bebb J, Mannath J et al. EUS-guided pancreatic cyst brushing:
a comparative study in a tertiary referral centre. JOP 2010; 11: 163
169
45 Sendino O, Fernndez-Esparrach G, Sol M et al. Endoscopic ultrasono-
graphy-guided brushing increases cellular diagnosis of pancreatic
cysts: A prospective study. Dig Liver Dis 2010; 42: 877 881
46 Al-Haddad M, Raimondo M, Woodward T et al. Safety and efficacy of cy-
tology brushings versus standard FNA in evaluating cystic lesions of
the pancreas: a pilot study. Gastrointest Endosc 2007; 65: 894 898
47 Nguyen YP, Maple JT, Zhang Q et al. Reliability of gross visual assess-
ment of specimen adequacy during EUS-guided FNA of pancreatic
masses. Gastrointest Endosc 2009; 69: 1264 1270
48 Kocjan G, Chandra A, Cross P et al. BSCC Code of Practice fine needle
aspiration cytology. Cytopathology 2009; 20: 283 296
49 Nasuti JF, Gupta PK, Baloch ZW. Diagnostic value and cost-effectiveness
of on-site evaluation of fine-needle aspiration specimens: review of
5,688 cases. Diagn Cytopathol 2002; 27: 1 4
50 Woon C, Bardales RH, Stanley MW et al. Rapid assessment of fine needle
aspiration and the final diagnosis how often and why the diagnoses
are changed. Cytojournal 2006; 3: 25
51 Chang KJ, Katz KD, Durbin TE et al. Endoscopic ultrasound-guided fine-
needle aspiration. Gastrointest Endosc 1994; 40: 694 699
52 Erickson RA, Sayage-Rabie L, Beissner RS. Factors predicting the number
of EUS-guided fine-needle passes for diagnosis of pancreatic malig-
nancies. Gastrointest Endosc 2000; 51: 184 190
53 Savides TJ, Donohue M, Hunt G et al. EUS-guided FNA diagnostic yield of
malignancy in solid pancreatic masses: a benchmark for quality per-
formance measurement. Gastrointest Endosc 2007; 66: 277 282
54 Eloubeidi MA, Jhala D, Chhieng DC et al. Yield of endoscopic ultrasound-
guided fine-needle aspiration biopsy in patients with suspected pan-
creatic carcinoma. Cancer 2003; 99: 285 292
55 Gress FG, Hawes RH, Savides TJ et al. Endoscopic ultrasound-guided
fine-needle aspiration biopsy using linear array and radial scanning
endosonography. Gastrointest Endosc 1997; 45: 243 250
56 Jhala NC, Jhala D, Eltoum I et al. Endoscopic ultrasound-guided fine-
needle aspiration biopsy: a powerful tool to obtain samples from small
lesions. Cancer 2004; 102: 239 246
57 Williams DB, Sahai AV, Aabakken L et al. Endoscopic ultrasound guided
fine needle aspiration biopsy: a large single centre experience. Gut
1999; 44: 720 726
58 Eloubeidi MA, Tamhane A, Jhala N et al. Agreement between rapid on-
site and final cytologic interpretations of EUS-guided FNA specimens:
implications for the endosonographer and patient management. Am J
Gastroenterol 2006; 101: 2841 2847
59 Wiersema MJ, Vilmann P, Giovannini M et al. Endosonography-guided
fine-needle aspiration biopsy: diagnostic accuracy and complication
assessment. Gastroenterology 1997; 112: 1087 1095
60 Cleveland P, Gill KRS, Coe SG et al. An evaluation of risk factors for inade-
quate cytology in EUS-guided FNA of pancreatic tumors and lymph
nodes. Gastrointest Endosc 2010; 71: 1194 1199
61 Iglesias-Garcia J, Dominguez-Munoz JE, Abdulkader I et al. Influence of
on-site cytopathology evaluation on the diagnostic accuracy of endo-
scopic ultrasound-guided fine needle aspiration (EUS-FNA) of solid
pancreatic masses. Am J Gastroenterol 2011; 106: 1705 1710
62 Cherian PT, Mohan P, Douiri A et al. Role of endoscopic ultrasound-
guided fine-needle aspiration in the diagnosis of solid pancreatic and
peripancreatic lesions: is onsite cytopathology necessary? HPB (Ox-
ford) 2010; 12: 389 395
63 Moller K, Papanikolaou IS, Toermer T et al. EUS-guided FNA of solid pan-
creatic masses: high yield of 2 passes with combined histologic-cytolo-
gic analysis. Gastrointest Endosc 2009; 70: 60 69
64 Wittmann J, Kocjan G, Sgouros SN et al. Endoscopic ultrasound-guided
tissue sampling by combined fine needle aspiration and trucut needle
biopsy: a prospective study. Cytopathology 2006; 17: 27 33
65 Pellis Urquiza M, Fernndez-Esparrach G, Sol M et al. Endoscopic ul-
trasound-guided fine needle aspiration: predictive factors of accurate
diagnosis and cost-minimization analysis of on-site pathologist. Gas-
troenterol Hepatol 2007; 30: 319 324
66 Layfield LJ, Bentz JS, Gopez EV. Immediate on-site interpretation of fine-
needle aspiration smears: a cost and compensation analysis. Cancer
2001; 93: 319 322
67 Savoy AD, Raimondo M, Woodward TA et al. Can endosonographers
evaluate on-site cytologic adequacy? A comparison with cytotechnol-
ogists. Gastrointest Endosc 2007; 65: 953 957
Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
Guideline 203
68 Hikichi T, Irisawa A, Bhutani MS et al. Endoscopic ultrasound-guided
fine-needle aspiration of solid pancreatic masses with rapid on-site
cytological evaluation by endosonographers without attendance of cy-
topathologists. J Gastroenterol 2009; 44: 322 328
69 LeBlanc JK, Ciaccia D, Al-Assi MT et al. Optimal number of EUS-guided
fine needle passes needed to obtain a correct diagnosis. Gastrointest
Endosc 2004; 59: 475 481
70 Turner BG, Cizginer S, Agarwal D et al. Diagnosis of pancreatic neoplasia
with EUS and FNA: a report of accuracy. Gastrointest Endosc 2010; 71:
91 98
71 Hoda KM, Rodriguez SA, Faigel DO. EUS-guided sampling of suspected
GI stromal tumors. Gastrointest Endosc 2009; 69: 1218 1223
72 Mekky MA, Yamao K, Sawaki A et al. Diagnostic utility of EUS-guided
FNA in patients with gastric submucosal tumors. Gastrointest Endosc
2010; 71: 913 919
73 Nguyen P, Feng JC, Chang KJ. Endoscopic ultrasound (EUS) and EUS-
guided fine-needle aspiration (FNA) of liver lesions. Gastrointest En-
dosc 1999; 50: 357 361
74 Singh P, Mukhopadhyay P, Bhatt B et al. Endoscopic ultrasound versus
CT scan for detection of the metastases to the liver: results of a pro-
spective comparative study. J Clin Gastroenterol 2009; 43: 367 373
75 Yoshida S, Yamashita K, Yokozawa M et al. Diagnostic findings of ultra-
sound-guided fine-needle aspiration cytology for gastrointestinal
stromal tumors: proposal of a combined cytology with newly defined
features and histology diagnosis. Pathol Int 2009; 59: 712 719
76 Papanikolaou IS, Adler A, Wegener K et al. Prospective pilot evaluation
of a new needle prototype for endoscopic ultrasonography-guided
fine-needle aspiration: comparison of cytology and histology yield.
Eur J Gastroenterol Hepatol 2008; 20: 342 348
77 Iglesias-Garcia J, Dominguez-Munoz E, Lozano-Leon A et al. Impact of
endoscopic ultrasound-guided fine needle biopsy for diagnosis of pan-
creatic masses. World J Gastroenterol 2007; 13: 289 293
78 Yasuda I, Tsurumi H, Omar S et al. Endoscopic ultrasound-guided fine-
needle aspiration biopsy for lymphadenopathy of unknown origin. En-
doscopy 2006; 38: 919 924
79 Voss M, Hammel P, Molas G et al. Value of endoscopic ultrasound guided
fine needle aspiration biopsy in the diagnosis of solid pancreatic mas-
ses. Gut 2000; 46: 244 249
80 Ardengh JC, Paulo GA, Nakao FS et al. Endoscopic ultrasound guided
fine-needle aspiration core biopsy: comparison between an automatic
biopsy device and two conventional needle systems. Acta Gastroenter-
ol Latinoam 2008; 38: 105 115
81 Turhan N, Aydog G, Ozin Y et al. Endoscopic ultrasonography-guided
fine-needle aspiration for diagnosing upper gastrointestinal submuco-
sal lesions: A prospective study of 50 cases. Diagn Cytopathol 2011;
39: 808 817
82 Ando N, Goto H, Niwa Y et al. The diagnosis of GI stromal tumors with
EUS-guided fine needle aspiration with immunohistochemical analy-
sis. Gastrointest Endosc 2002; 55: 37 43
83 Akahoshi K, Sumida Y, Matsui N et al. Preoperative diagnosis of gastro-
intestinal stromal tumor by endoscopic ultrasound-guided fine needle
aspiration. World J Gastroenterol 2007; 13: 2077 2082
84 Aithal GP, Anagnostopoulos GK, Tam W et al. EUS-guided tissue sam-
pling: comparison of dual sampling (Trucut biopsy plus FNA) with
sequential sampling (Trucut biopsy and then FNA as required). En-
doscopy 2007; 39: 725 730
85 Larghi A, Verna EC, Stavropoulos SN et al. EUS-guided trucut needle
biopsies in patients with solid pancreatic masses: a prospective study.
Gastrointest Endosc 2004; 59: 185 190
86 Saftoiu A, Vilmann P, Guldhammer Skov B et al. Endoscopic ultrasound
(EUS)-guided Trucut biopsy adds significant information to EUS-guid-
ed fine-needle aspiration in selected patients: a prospective study.
Scand J Gastroenterol 2007; 42: 117 125
87 Storch I, Shah M, Thurer R et al. Endoscopic ultrasound-guided fine-
needle aspiration and Trucut biopsy in thoracic lesions: when tissue
is the issue. Surg Endosc 2008; 22: 86 90
88 Storch I, Jorda M, Thurer R et al. Advantage of EUS Trucut biopsy com-
bined with fine-needle aspiration without immediate on-site cytopa-
thologic examination. Gastrointest Endosc 2006; 64: 505 511
89 Fernndez-Esparrach G, Sendino O, Sol M et al. Endoscopic ultrasound-
guided fine-needle aspiration and trucut biopsy in the diagnosis of
gastric stromal tumors: a randomized crossover study. Endoscopy
2010; 42: 292 299
204 Guideline
90 Gerke H, Rizk MK, Vanderheyden AD et al. Randomized study compar-
ing endoscopic ultrasound-guided Trucut biopsy and fine needle as-
piration with high suction. Cytopathology 2010; 21: 44 51
91 Gines A, Wiersema MJ, Clain JE et al. Prospective study of a Trucut nee-
dle for performing EUS-guided biopsy with EUS-guided FNA rescue.
Gastrointest Endosc 2005; 62: 597 601
92 Thomas T, Kaye PV, Ragunath K et al. Endoscopic-ultrasound-guided
mural trucut biopsy in the investigation of unexplained thickening of
esophagogastric wall. Endoscopy 2009; 41: 335 339
93 Thomas T, Kaye PV, Ragunath K et al. Efficacy, safety, and predictive fac-
tors for a positive yield of EUS-guided Trucut biopsy: a large tertiary
referral center experience. Am J Gastroenterol 2009; 104: 584 591
94 Kipp BR, Pereira TC, Souza PC et al. Comparison of EUS-guided FNA and
Trucut biopsy for diagnosing and staging abdominal and mediastinal
neoplasms. Diagnostic cytopathology 2009; 37: 549 556
95 Shah SM, Ribeiro A, Levi J et al. EUS-guided fine needle aspiration with
and without trucut biopsy of pancreatic masses. JOP 2008; 9: 422 430
96 Dewitt J, McGreevy K, Leblanc J et al. EUS-guided Trucut biopsy of sus-
pected nonfocal chronic pancreatitis. Gastrointest Endosc 2005; 62:
76 84
97 Gleeson FC, Clayton AC, Zhang L et al. Adequacy of endoscopic ultra-
sound core needle biopsy specimen of nonmalignant hepatic parench-
ymal disease. Clin Gastroenterol Hepatol 2008; 6: 1437 1440
98 Mizuno N, Bhatia V, Hosoda W et al. Histological diagnosis of autoim-
mune pancreatitis using EUS-guided trucut biopsy: a comparison
study with EUS-FNA. J Gastroenterol 2009; 44: 742 750
99 Song HJ, Park YS, Seo DW et al. Diagnosis of mediastinal tuberculosis by
using EUS-guided needle sampling in a geographic region with an in-
termediate tuberculosis burden. Gastrointest Endosc 2010; 71: 1307
1313
100 Eloubeidi MA, Mehra M, Bean SM. EUS-guided 19-gauge trucut needle
biopsy for diagnosis of lymphoma missed by EUS-guided FNA. Gas-
trointest Endosc 2007; 65: 937 939
101 Iglesias-Garcia J, Poley J-W, Larghi A et al. Feasibility and yield of a
new EUS histology needle: results from a multicenter, pooled, cohort
study. Gastrointest Endosc 2011; 73: 1189 1196
102 Behling C. A cytology primer for endosonographers. In: Hawes RH,
Fockens P eds. Endosonography. Philadelphia: Saunders Elsevier;
2006: 273 291
103 de Luna R, Eloubeidi MA, Sheffield MV et al. Comparison of ThinPrep
and conventional preparations in pancreatic fine-needle aspiration
biopsy. Diagn Cytopathol 2004; 30: 71 76
104 Wallace WA, Monaghan HM, Salter DM et al. Endobronchial ultra-
sound-guided fine-needle aspiration and liquid-based thin-layer cy-
tology. J Clin Pathol 2007; 60: 388 391
105 Arbyn M, Bergeron C, Klinkhamer P et al. Liquid compared with con-
ventional cervical cytology: a systematic review and meta-analysis.
Obstet Gynecol 2008; 111: 167 177
106 Fabre M, Ben-Lagha N, Palazzo L. La cytologie en milieu liquide peut-
elle remplacer la cytologie conventionnelle pour le diagnostic des
ponctions a laiguille fine sous choendoscopie? Rsultats dune
tude prospective multicentrique [abstract]. Gastroenterol Clin Biol
2003; 27: A66
107 Meara RS, Jhala D, Eloubeidi MA et al. Endoscopic ultrasound-guided
FNA biopsy of bile duct and gallbladder: analysis of 53 cases. Cytopa-
thology 2006; 17: 42 49
108 Rossi ED, Larghi A, Verna EC et al. Endoscopic ultrasound-guided fine-
needle aspiration with liquid-based cytologic preparation in the di-
agnosis of primary pancreatic lymphoma. Pancreas 2010; 39: 1299
1302
109 Berzosa M, Tsukayama DT, Davies SF et al. Endoscopic ultrasound-
guided fine-needle aspiration for the diagnosis of extra-pulmonary
tuberculosis. Int J Tuberc Lung Dis 2010; 14: 578 584
110 Michael H, Ho S, Pollack B et al. Diagnosis of intra-abdominal and
mediastinal sarcoidosis with EUS-guided FNA. Gastrointest Endosc
2008; 67: 28 34
111 Khashab M, Mokadem M, Dewitt J et al. Endoscopic ultrasound-guid-
ed fine-needle aspiration with or without flow cytometry for the di-
agnosis of primary pancreatic lymphoma a case series. Endoscopy
2010; 42: 228 231
112 Ribeiro A, Pereira D, Escaln MP et al. EUS-guided biopsy for the diag-
nosis and classification of lymphoma. Gastrointest Endosc 2010; 71:
851 855
113 Mortensen MB, Fristrup C, Holm FS et al. Prospective evaluation of pa-
tient tolerability, satisfaction with patient information, and compli-
Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
cations in endoscopic ultrasonography. Endoscopy 2005; 37: 146
153
114 Al-Haddad M, Wallace MB, Woodward TA et al. The safety of fine-nee-
dle aspiration guided by endoscopic ultrasound: a prospective study.
Endoscopy 2008; 40: 204 208
115 Bournet B, Migueres I, Delacroix M et al. Early morbidity of endoscopic
ultrasound: 13 years' experience at a referral center. Endoscopy
2006; 38: 349 354
116 Bentz JS, Kochman ML, Faigel DO et al. Endoscopic ultrasound-guided
real-time fine-needle aspiration: clinicopathologic features of 60 pa-
tients. Diagn Cytopathol 1998; 18: 98 109
117 Eloubeidi MA, Tamhane A, Varadarajulu S et al. Frequency of major
complications after EUS-guided FNA of solid pancreatic masses: a
prospective evaluation. Gastrointest Endosc 2006; 63: 622 629
118 Eloubeidi MA, Gress FG, Savides TJ et al. Acute pancreatitis after EUS-
guided FNA of solid pancreatic masses: a pooled analysis from EUS
centers in the United States. Gastrointest Endosc 2004; 60: 385 389
119 OToole D, Palazzo L, Arotarena R et al. Assessment of complications
of EUS-guided fine-needle aspiration. Gastrointest Endosc 2001; 53:
470 474
120 Polkowski M, Gerke W, Jarosz D et al. Diagnostic yield and safety of en-
doscopic ultrasound-guided trucut biopsy in patients with gastric
submucosal tumors: a prospective study. Endoscopy 2009; 41: 329
334
121 Janssen J, Knig K, Knop-Hammad V et al. Frequency of bacteremia
after linear EUS of the upper GI tract with and without FNA. Gastro-
intest Endosc 2004; 59: 339 344
122 Barawi M, Gottlieb K, Cunha B et al. A prospective evaluation of the
incidence of bacteremia associated with EUS-guided fine-needle as-
piration. Gastrointest Endosc 2001; 53: 189 192
123 Levy MJ, Norton ID, Clain JE et al. Prospective study of bacteremia and
complications with EUS FNA of rectal and perirectal lesions. Clin Gas-
troenterol Hepatol 2007; 5: 684 689
124 Levy MJ, Norton ID, Wiersema MJ et al. Prospective risk assessment of
bacteremia and other infectious complications in patients undergo-
ing EUS-guided FNA. Gastrointest Endosc 2003; 57: 672 678
125 Banerjee S, Shen B, Baron TH et al. Antibiotic prophylaxis for GI endos-
copy. Gastrointest Endosc 2008; 67: 791 798
126 Allison MC, Sandoe JAT, Tighe R et al. Antibiotic prophylaxis in gastro-
intestinal endoscopy. Gut 2009; 58: 869 880
127 Lee LS, Saltzman JR, Bounds BC et al. EUS-guided fine needle aspira-
tion of pancreatic cysts: a retrospective analysis of complications
and their predictors. Clin Gastroenterol Hepatol 2005; 3: 231 236
128 Aerts JGJV, Kloover J, Los J et al. EUS-FNA of enlarged necrotic lymph
nodes may cause infectious mediastinitis. J Thorac Oncol 2008; 3:
1191 1193
129 Annema JT, Veselic M, Versteegh MI et al. Mediastinitis caused by EUS-
FNA of a bronchogenic cyst. Endoscopy 2003; 35: 791 793
130 Jenssen C, Dietrich CF. Endoscopic ultrasound-guided fine-needle as-
piration biopsy and trucut biopsy in gastroenterology An overview.
Best Pract Res Clin Gastroenterol 2009; 23: 743 759
131 Erickson RA. EUS-guided FNA. Gastrointest Endosc 2004; 60: 267
279
132 Fazel A, Moezardalan K, Varadarajulu S et al. The utility and the safety
of EUS-guided FNA in the evaluation of duplication cysts. Gastroin-
test Endosc 2005; 62: 575 580
133 Affi A, Vazquez-Sequeiros E, Norton ID et al. Acute extraluminal he-
morrhage associated with EUS-guided fine needle aspiration: fre-
quency and clinical significance. Gastrointest Endosc 2001; 53:
221 225
134 Kien-Fong VuC, Chang F, Doig L et al. A prospective control study of the
safety and cellular yield of EUS-guided FNA or Trucut biopsy in pa-
tients taking aspirin, nonsteroidal anti-inflammatory drugs, or pro-
phylactic low molecular weight heparin. Gastrointest Endosc 2006;
63: 808 813
135 Varadarajulu S, Eloubeidi MA. Frequency and significance of acute in-
tracystic hemorrhage during EUS-FNA of cystic lesions of the pan-
creas. Gastrointest Endosc 2004; 60: 631 635
136 Brugge WR, Lewandrowski K, Lee-Lewandrowski E et al. Diagnosis of
pancreatic cystic neoplasms: a report of the cooperative pancreatic
cyst study. Gastroenterology 2004; 126: 1330 1336
137 Chee Y, Crawford J, Watson H et al. Guidelines on the assessment of
bleeding risk prior to surgery or invasive procedures. Br J Haematol
2008; 140: 496 504

138 Zuckerman MJ, Hirota WK, Adler DG et al. ASGE guideline: the man-
agement of low-molecular-weight heparin and nonaspirin antiplate-
let agents for endoscopic procedures. Gastrointest Endosc 2005; 61:
189 194
139 Anderson MA, Ben-Menachem T, Gan SI et al. Management of antith-
rombotic agents for endoscopic procedures. Gastrointest Endosc
2009; 70: 1060 1070
140 Boustire C, Veitch A, Vanbiervliet G et al. Endoscopy and antiplatelet
agents. European Society of Gastrointestinal Endoscopy (ESGE)
Guideline. . Endoscopy 2011; 43: 445 461
141 Gress F, Michael H, Gelrud D et al. EUS-guided fine-needle aspiration
of the pancreas: evaluation of pancreatitis as a complication. Gastro-
intest Endosc 2002; 56: 864 867
142 Di Matteo F, Shimpi L, Gabbrielli A et al. Same-day endoscopic retro-
grade cholangiopancreatography after transduodenal endoscopic ul-
trasound-guided needle aspiration: do we need to be cautious? En-
doscopy 2006; 38: 1149 1151
143 Hirooka Y, Goto H, Itoh A et al. Case of intraductal papillary mucinous
tumor in which endosonography-guided fine-needle aspiration
Polkowski M et al. Learning, techniques, and complications of EUS-guided sampling Endoscopy 2012; 44: 190205
Guideline 205
biopsy caused dissemination. J Gastroenterol Hepatol 2003; 18:
1323 1324
144 Paquin SC, Garipy G, Lepanto L et al. A first report of tumor seeding
because of EUS-guided FNA of a pancreatic adenocarcinoma. Gastro-
intest Endosc 2005; 61: 610 611
145 Eloubeidi MA, Tamhane A, Lopes TL et al. Cervical esophageal perfora-
tions at the time of endoscopic ultrasound: a prospective evaluation
of frequency, outcomes, and patient management. Am J Gastroenter-
ol 2009; 104: 53 56
146 Doi S, Yasuda I, Iwashita T et al. Needle tract implantation on the
esophageal wall after EUS-guided FNA of metastatic mediastinal lym-
phadenopathy. Gastrointest Endosc 2008; 67: 988 990
147 Shah JN, Fraker D, Guerry D et al. Melanoma seeding of an EUS-guided
fine needle track. Gastrointest Endosc 2004; 59: 923 924
148 Micames C, Jowell PS, White R et al. Lower frequency of peritoneal car-
cinomatosis in patients with pancreatic cancer diagnosed by EUS-
guided FNA vs. percutaneous FNA. . Gastrointest Endosc 2003; 58:
690 695
Appendix 1 and 2 are available online:
online content viewable at:
www.thieme-connect.de/ejournals/abstract/endoscopy/
doi/10.1055/s-0031-1291543